“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”:Commentary

In this commentary,we summarize some of the key points of the original paper“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”and offer support for the proposed results.Specifically,we address how early percutaneous endoscopic gastrostomy(PEG)tube placement may reduce hospital length of stay and costs.We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation.However,we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed,and further research is needed.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes

BACKGROUND Percutaneous Endoscopic Gastrostomy(PEG)tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake.The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks,as half of patients with dysphagia improve within 2 wk.There are few studies comparing outcomes based on timing of PEG tube placement,and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.AIM To assess the safety of early(≤7 d post stroke)vs late(>7 d post stroke)PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.METHODS We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis,MO between January 2011 and December 2017.Patients were identified by keyword search of endoscopy reports.Mortality,peri-procedural complication rates,and post-procedural complication rates were compared in both groups.Predictors of morbidity and mortality such as protein-calorie malnutrition,presence of an independent cardiovascular risk equivalent,and presence of Systemic inflammatory response syndrome(SIRS)criteria or documented infection were evaluated by multivariate logistic regression.RESULTS 154 patients had a PEG tube placed for dysphagia following a stroke,92 in the late group and 62 in the early group.There were 32 observed deaths,with 8 occurring within 30 d of the procedure.There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant.Hospital length of stay was significantly less in patients with early PEG tube placement(12.9 vs 22.34 d,P<0.001).Protein calorie malnutrition,presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.CONCLUSION Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay.Given similar safety outcomes in both groups,early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.